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Today's Date
Month
Day
Year
Date of Last Tetanus Shot
Month
Day
Year
PHOTO AUTHORIZATION: Pictures are taken at church sponsored events. I hereby give my permission for photos of my child/youth (if participant is under 18) or myself (if participant is 18 or over) to be posted on printed church media and online.

 FOR PARTICIPANTS 18 AND OVER:

I authorize any St. Mark UMC staff member, adult volunteer or adult chaperone present at any church activity to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care to be rendered to me under the general or special supervision of health care providers and on the advice of a properly licensed physician or surgeon.   I understand and agree that, in the event that I suffer an injury that requires medical treatment, the above named adults may authorize immediate treatment and/or first aid.

Concerning the above statement:

FOR PARTICIPANTS 17 AND UNDER:

 

 As parent of my child (hereinafter referred to as “child”), I give permission for my child to attend and participate in any St. Mark United Methodist Church activity. I understand and acknowledge that while St. Mark United Methodist Church and its agents, staff members, volunteers, and other personnel shall make all reasonable efforts to protect the health, safety and welfare of my child, that my child will be participating in strenuous physical activities, sports and recreation, which bear the risk of severe or even terminal physical injury.  I further understand and acknowledge that my child will be transported in vehicles, which may be operated by St. Mark UMC staff or adult volunteers, or may be chartered with third party carriers.  I therefore give permission for my child to participate in these activities, having been fully advised of the potential risks of participation thereto.

 

            Furthermore, as parent and legal guardian of my child, I authorize any St. Mark UMC staff member, adult volunteer or adult chaperone present at the above activities to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care to be rendered to my child under the general or special supervision of health care providers and on the advice of a properly licensed physician or surgeon.   I understand and agree that, in the event my child suffers an injury that requires medical treatment, the above named adults may authorize immediate treatment and/or first aid regardless of whether they are able to contact me regarding my child’s treatment.

 

(I further understand that my child will be responsible for administering their own medications, unless special arrangements are made in writing with the ST. MARK UMC approved adult in charge of the event prior to embarking on the above activity.)

 

Concerning the above statement:
By clicking “I Agree,” I certify that all information provided above is true, complete, and accurate to the best of my knowledge as of today’s date.
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